Retinopathy.ppt

5/28/2018 Retinopathy.ppt

1/57

RetinopathyRidwan Hadinata Salim

(I11109037)


2/57

Definition

General term that refers to some form of

non-inflammatory damage to the retina of the

eye.

Frequently, retinopathy is an ocular

manifestation of systemic disease.


3/57

DIABETIC RETINOPATHY


4/57

Definition

Progressive dysfunction of the retinal blood

vessels caused by chronic hyperglycemia.

Diabetic Retinopathy can be a complication of

diabetes type 1 or diabetes type 2.

Initially, Diabetic Retinopathy is asymptomatic,

if not treated though it can cause low vision and

blindness.


5/57

Diabetic retinopathy symptoms

Diabetic retinopathy is asymptomatic in early stages of thedisease

As the disease progresses symptoms may include

Blurred vision

Floaters

Fluctuating vision

Distorted vision

Dark areas in the vision

Poor night vision

Impaired color vision

Partial or total loss of vision


6/57

Risk factors

Duration of diabetes

Poor Blood Sugar control Hypertension

Hyperlipidemia

Barriers to care


7/57

Risk factors Diabetic Retinopathy

Duration of diabetes is a major riskfactor associated with the development

of diabetic retinopathy

The severity of hyperglycemia is the key

alterable risk factor associated with thedevelopment of diabetic retinopathy


8/57

How diabetes cause vision loss

HOW DIABETES CAUSES VISION LOSS

Preclinical

changes

Macular

edema

ProliferativeDR

DiabetesBackground

DR

Clinical

significant

macular edema

Vitreous hemorrhage

and/or Retinaldetachment and/or

neovascular glaucoma

PreproliferativeDR

Vision

loss


9/57

Pathophysiology

Diabetic Retinopathy is a microvasculopathy

that causes:

Retinal capillary occlusion

Retinal capillary leakage


10/57

Microvascular Occlusion

Microvascular occlusion is caused by:

Thickening of capillary basement membranes

Abnormal proliferation of capillary endothelium

Increased platelet adhesion Increased blood viscosity

Defective fibrinolysis


11/57

Cottonwool spot

Neovascularization

Ischemia

Neovascular

glaucoma

Microvascular

Occlusion

Fibrovascular bandsVitreous

hemorrhage

Increased VEFG

Tractional retinal

detachment

Infarction


12/57

Microvascular leakage

Microvascular leakage is caused by:

Impairment of endothelial tight junctions

Loss of pericytes

Weakening of capillary walls Elevated levels of vascular endothelial growth factor (VEGF)


13/57

EdemaRetinal

hemorrhageHard exudates

Microvascular Leakage


14/57

Classification of diabetic retinopathy

A useful classification according to the types oflesions detected on fundoscopy is as follows:

Non-proliferative diabetic retinopathy (NPDR)

Proliferative diabetic retinopathy

Maculopathy


15/57

No retinopathy


16/57

MILD NONPROLIFERATIVE DIABETIC

RETINOPATHY

Characteristics

Microaneurysms only


17/57

Microaneurysms

Retinal microaneurysms are focal dilatations of retinal

capillaries, 10 to 100 microns in diameter, and appear as reddots. They are usually seen at the posterior pole, especiallytemporal to the fovea. They may apparently disappear whilstnew lesions appear at the edge of areas of widening capillarynon-perfusion. Microaneurysms are the first

ophthalmoscopically detectable change in diabeticretinopathy.

Beginning as dilatations in areas in the capillary wall wherepericytes are absent, microaneurysms are initially thin-walled.Later, endothelial cells proliferate and lay down layers ofbasement membrane material around themselves.


18/57

Fibrin and erythrocytes may accumulate within the aneurysm.

Despite multiple layers of basement membrane, they are

permeable to water and large molecules, allowing the

accumulation of water and lipid in the retina. Since

fluorescein passes easily through them, many moremicroaneurysms are usually seen on fluorescein angiography

than are apparent on ophthalmoscopy


19/57

MILD NONPROLIFERATIVE DIABETIC

RETINOPATHY

Microaneurysms


20/57

Moderate Nonproliferative Diabetic

Retinopathy (NPDR)

Characteristics

More than just microaneurysms but less than severe NPDR


21/57


Retinopathy (NPDR)

Hard exudates

Flamed shaped

hemorrhage

Microaneurysm


22/57


Retinopathy (NPDR)

Hard exudates

microaneurysm


23/57

Severe Nonproliferative Diabetic

Retinopathy (NPDR)

Any of the following:

More than 20 intraretinal hemorrhages in each of

four quadrants

Definite venous beading in two or more quadrants

Prominent Intraretinal Microvascular Abnormalities

(IRMA) in one or more quadrants

No signs of proliferative retinopathy


24/57

Severe Nonproliferative Diabetic Retinopathy

(NPDR)

Venous beading


25/57

Proliferative Diabetic Retinopathy (PDR)

Characteristics

Neovascularization

Vitreous/preretinal

hemorrhage


26/57

PROLIFERATIVE

DIABETIC

RETINOPATHY

Neovascularization

Hard exudate

Cotton-wool

spot

Blot hemorrhage


27/57

High-Risk Proliferative diabetic retinopathy

At risk for serious vision loss

Any combination of three of the following four findings

Presence of vitreous or preretinal hemorrhage.

Presence of new vessels (neovascularization, NV) Location of NV on or near the optic disc.

Moderate to severe extent of new vessels.


28/57

Diabetic macular edema

Diabetic macular edema is the leading cause of legal

blindness in diabetics.

Diabetic macular edema can be present at any stage

of the disease, but is more common in patients withproliferative diabetic retinopathy.


29/57

Meta analysis and review on the effect on bevacizumab id diabetic macular edema

Graefes Arch Clin Exp Ophthalmol(2011) 249:15-27


30/57

Why is Diabetic macular edema so important?

The macula is responsible for central vision.

Diabetic macular edema may be asymptomatic atfirst. As the edema moves in to the fovea (the centerof the macula) the patient will notice blurry centralvision. The ability to read and recognize faces will becompromised.

Macula

Fovea


31/57

Normal Macular Edema


32/57

Clinically significant macular edema

(CSME)

Thickening of the retina at or within 500 m of the

center of the macula.

Hard exudates at or within 500 m of the center of

the macula, if associated with thickening of theadjacent retina.

Area of retinal thickening 1 disc area or larger, within

1 disc diameter of the center of the macula.


33/57

International Clinical Diabetic Macular Edema

Disease Severity Scale

Proposed disease severity level Findings observable upon dilated

ophthalmoscopy

DME apparently absent

DME apparently present

DME present

No apparent retinal thickening or hard exudates in

posterior pole

Some apparent retinal thickening or hard exudatesin posterior pole

Mild DME (some retinal thickening or hard exudates

in posterior pole but distant from the center of the

macula)

Moderate DME (retinal thickening or hard

exudates approaching the center of the macula but

not involving the center)

Severe DME (retinal thickening or hard exudates

involving the center of the macula)Proposed International Clinical DiabeticRetinopathy and Diabetic Macular Edema

Disease Severity Scales

Ophthalmology Volume 110, Number 9, September 2003


34/57

DIABETIC RETINOPATHY TREATMENT

The best measure for prevention of

loss of vision from diabetic

retinopathy is strict glycemiccontrol


35/57

Laser Photocoagulation

Laser Photocoagulation is recommended for eyes with:

Clinical significant macular edema CSME

High risk Proliferative diabetic retinopathy


36/57


Once DR threatens vision treatments can include:

Laser therapy to seal leaking bloodvessels (focal laser)

Laser therapy to reduce retinal oxygendemand (scatter laser)

Surgical removal of blood from the eye(vitrectomy)


37/57


NEWER DEVELOPMENTS:

The use of anti-vascular endothelial

growth factor antibodies has beenshown to be useful in the treatment ofDR

Anti-VEGF antibody treatment appearsto be useful for both macular edema andproliferative retinopathy

Studies to determine the exact role ofanti-VEGF treatment in relation to lasertreatment in specific situations areunderway.


38/57

CONCLUSIONS

Diabetic Retinopathy is

preventable through strict

glycemic control and annual

dilated eye exams by an

ophthalmologist.


39/57

HYPERTENSIVE

RETINOPATHY


40/57

Hipertensive Retinopathy

A condition characterized by a spectrum of

retinal vascular signs in people with elevated

blood pressure.

Arterial changes in hypertension are primarily

caused by vasospasm; in arteriosclerosis they

are the result of thickeningof the wall of the

arteriole.


41/57

Pathophysiology

1. Vasoconstrictive stage

2. Sclerotic stage

3. Exudative stage


42/57

Pathophysiology

Vasoconstrictive stage

blood pressure

Retinal arteriol vasoconstrictive

(local autoregulatory mechanisms)

Generalized narrowing of the

retinal arterioles.


43/57

Sclerotic stage

Persistently elevated blood pressure

Intimal thickening, media wallhyperplasia, hyaline degeneration

Changes in the arteriolar andvenular junction (arteriovenous

nicking or nipping)


44/57

Exudative stage

Disruption of the bloodretina barrier

Necrosis of the smooth muscles andendothelial cells exudation of blood

and lipids, and retinal ischemia

Microaneurysms, hemorrhages, hard

exudates, and cotton-wool spots.


45/57


46/57

Classifications

Arteriolar Sclerosis Aging causes thickening and sclerosis of the

arterioles

Prolonged systemic hypertension (usually diastolicpressure greater than100 mm Hg).

The amount of arteriolar sclerosis depends on

duration and severity of the hypertension and

may reflection the condition of the arterioleselsewhere in the body.


47/57

Elevated Blood Pressure

A moderate acute rise in blood pressure results inconstriction of the arterioles.

A severe acute rise in blood pressure (usually, diastolic

pressure greater than 120 mmHg) causes fibrinoid

necrosis of the vessel wall, resulting in exudates,cotton-wool spots, flame-shaped hemorrhages, and

sometimes whitish swelling and edema of large

portions of the retina.

In the most severe form of hypertensive retinopathy,malignant hypertension the optic disc swelling that

occurs resembles the swelling seen in papilledema.


48/57

Hypertensive retinopathy: haemorrhages,

cotton-wool spots, exudates, vascular calibre

changes.


49/57


50/57


51/57


52/57


53/57

Symptoms

Headaches

Visual disturbances, and sometimes sudden

vision loss


54/57


55/57

Treatment

Control of high blood pressure (hypertension)

is the only treatment for hypertensive

retinopathy.


56/57


57/57

Thank You

Documents

Retinopathy.ppt